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27 March 2009

Cougar S-92 timeline: TSB

The Transportation Safety Board released a time line for Cougar’s CHI91, the Sikorsky S-92 that crashed two weeks ago. Compare it to one published online at the time of the incident. The TSB timeline is given in ZULU while the flightaware.com tracklog is converted from ZULU to Eastern Daylight. Local time for the incident is ZULU – 3.5.

One of the questions the timeline raises is the search and rescue helicopter response time. Not the Cormorant’s from 103 Squadron in Gander, mind you but Cougar’s own SAR helo.

If we take CHI91’s MAYDAY as minute zero, the figures get interesting.

Cougar should have an operations base monitoring the flight and its radio communications. There would likely also be a channel available so that the pilots can speak directly to the company’s maintenance and senior pilot team.

With that said, Cougar Base at St. John’s airport should have been aware of the emergency no later than M+0, the same time that Gander received the MAYDAY.

The aircraft ditches at M+11.

At M+11 Cougar base advises that they will launch Cougar 61, the SAR helicopter. The company had been operating as back-up to 103 and knew at that time that the air force SAR response was an additional one hour flying time away.

Cougar 61 does not launch until M+43.

Cougar 61 arrives on scene 18 minutes later. An aircraft 18 minutes flying time away takes 43 minutes to get airborne and that’s in a situation where the aircraft ought to have been ready as a matter of normal procedure and the despatchers knew from the outset that there was a potentially catastrophic problem with the aircraft.

We can say they knew it was potentially catastrophic because they know the importance of the main gearbox oil pressure to continued flight. Heck, they would have known about the Broome incident that had led to the January Sikorsky directive.

This is one of many questions that the TSB investigation will undoubtedly address with typical thoroughness.

Nothing released by TSB on Thursday raised any issues with personal locator beacons or immersion suits.

11 comments:

yeah danny wanted to focus on the dated stated not knowing the offshore survival suit is built to two standards with one of them updated in 2005. why he wanted to go before the media with this who knows but the real focus should be on cougar's chopper and emergency procedures.

This raises some good questions as to why Cougar took so long to respond with their own search and rescue flight. Cougar’s response flight did not launch until 43 minutes after mayday, but when it did launch, took only 18 minutes to reach the scene. Had they arrived on scene more timely, it may be that not only Robert Decker but also the second passenger who escaped the shattered copter body, Allison Maher, would have survived. It is unlikely to have helped the 16 people found inside the fuselage on the bottom of the sea.

I have taken a different tack in my piece posted March 27 on Newfoundland Injury Law Blog, and focused on the 30 minute dry run requirement. Cougar flight 491 flew dry for only 11 minutes, then crashed with tremendous force. Another 19 minutes dry running would have delivered those imperiled to safe haven at Cape Spear, with a safe fly margin to spare.

The truth is that much of the comments about the PLB's on the morning of the crash were clouded by conflicting facts from the various SAR responders. The fog of the moment if you will. Cougar did in fact pick up the PLB signals from the two personnel in the water and this was confirmed on Sunday but the military did not. The fact is they were far beyond the range of the beacons when Cougar had the survivor and deceased removed from the water and turned the units off. Not picking up any beacons when they did arrive on scene meant the worst case fro me.

Cougar does not always have two dedicated SAR Techs in the hanger at all times but do have resources on call for immediate deployment. All things considered to have the first rescue chopper in the air 32 minutes after the chopper ditched is not that bad considering that the ready/up time for the military SAR crews is 30 minutes as well.

Since they were the dedicated/designated back-up to 103 and knew they were on point since 103 was out of the immediate area, I find it astonishing that they were in such a relaxed (relative choice of words) state of readiness.

103s ready time is 15 minutes to launch during daylight and 45 mins after hours. The only way to shorten that daylight time is to have peiople sitting in seats waiting for a launch order or at night to have people working night shifts with an aircraft rady to go as well.

Overall, given that in any case Cougar would likely be the first helo to any scene east of St. John's (odds are 103 will not be in the area given the size of the territory they cover) I'd consider that to be a pretty relaxed state of readiness.

There are times when people signing anonymously is frustrating and this is one of them. You seem to have some direct knowledge so it would be helpful to know what it is and where it comes from.

From my review of the newser videos, there is some conflict and confusion.

That seems to be a result of the way this emergency was handled overall, at least from the newser perspective: it wasn't obvious to me who was in charge. As good as things were that's one point from an emergency comms perspective I hope someone gets a huge grip on for any future contingency.

Still, I took away right from the outset that one set of PLBS had worked since there were unequivocal statements of that on Day One. The next day, in a different context you get a different answer but people should be able to piece things together.

That confusion didn't come on the morning of but on the late afternoon and next day after.

In the morning, there were bags of rumour flying around town that, in hindsight could only have come from sources who were pretty close to the operation or had access to the radio comms back and forth with CHI91.

Where is the 15 and 45 minute time frames coming from? Daytime response time is 1 hour from callout to airbourne and 2 hours after hours as was proven with the Melinda & Keith II tragedy and again in Checkmate III. Maybe some better response time lines can be put in place but its not like jumping in a fire truck and turning the key. Pre-flight checks and protocols take time as well as flight crew preparations which include briefings. I personally think 103 and Cougar are doing a great job given the system and equipment they are working with. That said there will always be room for improovement as technology changes and requirements change. Gander is a central location for ALL NL and the oil fields are only a part of NL albiet an important part but so are our offshore fishing fleet.

I double-checked and my recollection was faulty. Then again, your version was off a wee bit too.

The TSB report on the Melina and Keith contains this information:

"Although the vessel capsized a half hour before the end of regular Department of National Defence (DND) working hours, for which DND has a 30-minute response standard, tasking of SAR air resources occurred after working hours. As such, the primary SAR air resources at Canadian Forces Base Gander were operating on the quiet hour standard of a two-hour (maximum) response time. The response helicopter (R908) departed for the scene 80 minutes after being tasked and it is not possible to determine the impact of this on the eventual outcome."

In other words:

- 30 mins during working hours.- maximum two hours response time during quiet hours.

That quiet hours time is given as a maximum meaning that it would be posible in some circumstances to reduce the times involved.

Great job? Agreed.

But where is this business about "the system and equipment" coming from?

Both the 101 and the 92 are modern, powerful state-of-the-art aircraft. They are well-maintained by top notch maint teams and crewed in flight by top notch pilots, navs and SAR techs.

As for the time lags from tasking to launch, those can be cut down by a variety of protcols and that minimise the time that needs to be spent on pre-flights etc. it can be done. People just need to make the decisions and allocate the funds to do it.

And hey, next time sign your name. If you are going to make a solid contribution, why not stand behind it?